Health-system-based interventions to improve care in pediatric and adolescent type 1 diabetes.

Despite significant advances in pharmacology and technology, glycemic targets are difficult to achieve for patients with type 1 diabetes (T1D) and management remains burdensome for patients and their families. Quality improvement (QI) science offers a methodology to identify an aim, evaluate complex contributors to the goal, and test potential interventions to achieve outcomes of interest. Day-to-day management of diabetes is often an iterative process but interventions exist at all care levels: individual patient and family, clinic, and larger population and health system. This article reviews current literature and proposes novel QI interventions for enhancing health outcomes, with attention to essential determinants or drivers of improved glycemic control and patient experience for pediatric T1D in the context of the Chronic Care Model. In-depth consideration of key drivers of successful T1D care, including self-management and integration of technology, are explored, and examples of larger health systems with improved outcomes, including Learning Health Systems are highlighted.

Evidence-based recommendations for the treatment of aggression in pediatric patients with attention deficit hyperactivity disorder.

An evidence-based practice project was completed to develop best practice recommendations for the treatment of aggression in children and adolescents with attention deficit hyperactivity disorder (ADHD). Ovid Medline, PsychInfo, the National Guidelines Clearinghouse, and the Cochrane Database of Systematic Reviews were searched with limits set for English language, years 1996 to January 2010. A search of the pediatric literature was conducted for synthesized evidence in the form of meta-analyses, systematic reviews, or practice guidelines related to the treatment of aggression in children and adolescents with attention deficit hyperactivity disorder. Data were extracted using the LEGEND system. Three evidence-based care recommendations for the management of aggression in children and adolescents with ADHD were developed with an associated grade for the body of evidence. First-line pharmacotherapy for aggressive behavior in children and adolescents with ADHD should be ADHD medications. Additional research is needed to evaluate the efficacy of psychiatric medications on signs of aggression within the context of ADHD.

Improving Telehealth Knowledge in Nurse Practitioner Training for Rural and Underserved Populations.

BACKGROUND: Telehealth is an emerging technology for the delivery of health care services. Providers need to be trained to maximize the potential benefits for rural and underserved populations. METHOD: A quality improvement approach to curricular redesign was used to integrate telehealth in a family nurse practitioner program. The intervention consisted of telehealth learning outcomes and a lecture-style presentation in a role transition course. A Plan-Do-Study-Act cycle informed faculty decision making in a small test of change. Self-reported confidence in telehealth knowledge was measured with a knowledge survey to determine whether the change was an improvement. RESULTS: Student confidence in telehealth knowledge increased following the intervention. The change provided an opportunity for faculty to consider additional approaches to integrating telehealth learning experiences in practicum courses. CONCLUSION: This project provided an improvement framework on which faculty can build and test effective pedagogical approaches to training graduate nursing students on the use of telehealth technology. [J Nurs Educ. 2019;58(1):57-60.].

Electronic health records in an outpatient breastfeeding medicine clinic.

The Institute of Medicine has issued a call for the implementation of computer-based patient records. The purpose of this overview is to describe the content developed for an electronic health record in an outpatient breastfeeding medicine clinic at a pediatric health care facility. Additional features of the computer system, including electronic prescriptions, printed patient handouts, and follow-up telephone notes, utilized in this setting are also described. As more hospital systems and outpatient offices adopt electronic medical record systems, the authors recommend that lactation personnel work with administrators and computer professionals at their institution to incorporate the special needs of an outpatient lactation clinic into their system.

The development of a research human milk bank.

Although there are well-established clinical human milk banks in the United States, there are no milk banks specifically intended to foster research on human milk. The authors' goal was to establish a milk bank with a core data set to support exploratory and hypothesis-driven studies on human milk. Donations to the Cincinnati Children's Research Human Milk Bank are accepted within the context of ongoing, hypothesis-driven research or on an ad hoc basis. Donors must give informed consent, and scientists wishing to use the samples must have Institutional review board approval for their use. Development of more research human milk banks can potentially provide resources for multidisciplinary collaboration and advance the study of human milk and lactation.

Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis.

BACKGROUND: Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients. OBJECTIVES: To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes. DATA SOURCES: We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan. STUDY ELIGIBILITY CRITERIA: We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes. STUDY APPRAISAL AND SYNTHESIS METHODS: We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction. RESULTS: Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD -1.20, 95% CI -2.01 to -0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI -0.04 to 0.78, P = .08). LIMITATIONS: Included studies were heterogeneous in nature, including their conceptions of SDM. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).

Should breastfeeding mothers avoid allergenic foods?

Questions about maternal diet in lactation are common in clinical nursing practice, for nurses often work with breastfeeding women who are concerned about allergies, or who associate infant symptoms of crying or irritability to something they themselves have eaten. Can exposure to food proteins in a woman's diet actually cause food allergy in her breastfed child? Are special diets effective in managing infant allergic symptoms or gastrointestinal distress? The purpose of this article is to review the evidence related to diet for new breastfeeding mothers and make recommendations to guide clinical practice; seven such practice recommendations were developed after a thorough literature review. Nurses can use this literature summary to provide care based upon the best available research evidence.

Guidelines for establishing a donor human milk depot.

Human milk is the preferred choice for infant feeding. When a sick or premature infant's own mother's milk is unavailable, donor human milk is becoming more widely used. Many potential milk donors do not live within close proximity to the 10 North American not-for-profit milk banks. Transporting milk via commercial carriers can be inconvenient and costly for recipient banks. A network of donor human milk depots is one practical way to increase the quantity of available donor human milk. This article provides guidelines and practical suggestions for establishing a donor human milk depot.